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Network Participation Request

Please complete the following form only if you are a masters level counselor or above. You must input a correct CAQH number or a valid license number with date of birth. You must have a professional office location. (Note: office space in your primary residence is prohibited)
If you have questions regarding the credentialing process or would like to inquire if we have business in your area, please contact the Network Management Department at 1-888-266-9041 Ext 2903.

Note: A separate request must be completed for each service location. Requests will be kept on file for one year. A network management representative will contact you within 3-5 business days.